Alcohol use and related problems among ethnic minorities in the United States.

Alcohol use patterns and the prevalence of alcohol-related problems vary among ethnic groups. Among the elements thought to account for these ethnic differences are social or cultural factors such as drinking norms and attitudes and, in some cases, genetic factors. Understanding ethnic differences in alcohol use patterns and the factors that influence alcohol use can help guide the development of culturally appropriate alcoholism treatment and prevention programs.

thnic minorities currently make up about 29 percent of the U.S. population (U.S. Census Bureau 2001). 1 This article reviews the main research findings on the alcohol consumption patterns and related problems of the four main ethnic minority groups in the United States: Hispanics, Blacks, Asian Americans, and Native Americans. Comparison data are often given for Whites, who make up the majority group in the United States. An understanding of the similarities and differences in alcohol consumption that exist among these ethnic groups and the differences that distinguish them from Whites can guide the development of alcoholism preven tion and treatment programs to meet the needs of members of these groups. Although recent alcohol research has emphasized the heterogeneity that exists within each ethnic group (Caetano et al. 1998), detailed exami nation of within-group differences is beyond the scope of this article.

Alcohol Consumption Patterns Among U.S. Minority Groups
Patterns of alcohol consumption have been found to vary across ethnic groups. Surveys of nationally repre sentative samples of people age 18 and older conducted in 1984 and 1995 found that the rates of alcohol abstention remained stable among White men but increased among Black and Hispanic men (see table 1) (Caetano and Clark 1998a).
This study also found that fre quent heavy drinking (defined as drinking five or more drinks at a sit ting at least once a week 2 ) decreased among White men but remained sta ble among Black and Hispanic men. 3 Among women, abstention rates increased among all three groups, with the highest increases occurring among Blacks and Hispanics com pared with Whites. Women's rates of frequent heavy drinking mirrored

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those of men, with a decrease in heavy drinking among White women and stability of rates for Black and Hispanic women. Several factors were associated with the likelihood of current fre quent heavy drinking for the three groups (Caetano and Clark 1998a years of age and reporting that reli gion was important in their lives. No specific risk factors were found for Black men; protective factors included being retired and defining religion as important in their lives. Among Hispanic men, unemployment was the only identified risk factor.
Among White women, never hav ing married was a risk factor for fre quent heavy drinking, and being older than 50 was a protective factor. Among Black women, lower income and unemployment were risk factors. Black women between the ages of 50 and 59 were less likely to report fre quent heavy drinking than those between 18 and 29. A risk factor for Hispanic women was unemployment; protective factors included older age, retirement, and defining religion as important in their lives.
Data from the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES) found drinking patterns for Native Americans to be sim ilar to those of Blacks and Hispanics (specifically, Mexican Americans) (Dawson 1998). Compared with Whites, Native Americans are less likely to drink-that is, a greater per centage of the population abstainsbut they consume more alcohol when they do drink, as is the case for both Blacks and Mexican Americans.
Heterogeneity in drinking patterns is also found among different nation alities within specific ethnic groups (Dawson 1998). Blacks whose ancestry is Caribbean consume less alcohol com pared with Blacks in general. Hispanic Americans of Central American, South American, or Caribbean ancestry con sume less alcohol than Hispanics in general (including Hispanics of Mexican or Mexican American ancestries). Among Asians, Japanese Americans consume more alcohol than Asian Americans of other national origins (Dawson 1998). Heterogeneity in drinking patterns also varies by place of birth. For example, Asians and Pacific Islanders born in the United States have lower alcohol abstention rates than those born elsewhere (Makimoto 1998).
Differences in alcohol consump tion are also found among Native Americans. Those living on reserva tions drink less frequently than Native Americans living in off-reservation towns, but reservation dwellers may engage in binge drinking (drinking five or more drinks per day) more fre quently and consume more alcohol per occasion when they do drink (May and Gossage 2001).

Alcohol-Related Problems
Excessive alcohol consumption can cause social problems such as divorce or job loss and legal problems such as driving under the influence, as well as alcohol abuse and dependence. Sur veys conducted in 1984 and 1995 using national probability samples of people age 18 and older found that the proportions of White and Black men reporting one, two, or three or more alcohol-related problems (such as withdrawal, tolerance, accidents, problems with the police, and prob lems with a spouse) were relatively stable from one time to the next (see table 2) (Caetano and Clark 1998b). However, the proportion of Hispanic men reporting three or more prob lems almost doubled between the two time periods (increasing from 9 percent to 16 percent). Among women of all three ethnic groups, problem preva lence was relatively stable across the two time periods. Several factors were associated with the likelihood of having alcoholrelated problems (Caetano and Clark 1998b). For both genders and all three groups, older people were less likely to report having alcohol-related problems than younger people. For all groups, the amount of alcohol a person consumed per week was posi tively associated with the likelihood of having alcohol-related problems. Sep arated, divorced, or never married White men and women had a higher risk of alcohol-related problems than those who were married. Among Black men, being widowed was asso ciated with a lower risk for alcoholrelated problems compared with mar ried men. Among Hispanic men, the unemployed had a higher likelihood of alcohol-related problems than those who were employed, and Hispanic men with incomes of $40,000 or more had a lower likeli hood of reporting alcohol-related problems than those whose incomes were less than $10,000.
Among Black women, homemakers or unemployed women had a higher likelihood of having alcoholrelated problems than employed women. Among Hispanic women, those who were retired had a lower likelihood of having such problems than those who were employed.
Variation in alcohol-related prob lems has also been found to exist within specific ethnic groups. For example, among Hispanics, Mexican Americans have been found to have more alcohol-related problems than those of Cuban and Puerto Rican ori gins (Caetano et al. 1998).
Information about the prevalence of the specific problems of alcohol abuse and dependence also comes from the National Comorbidity Survey (NCS), a nationally representative household survey of people ages 15 to 54, which used diagnostic interviews to estimate the prevalences of alcohol and other drug abuse disorders (Kes sler et al. 1994). This study found that Blacks have significantly lower rates of substance use disorders in general than Whites. However, the NCS did not find a difference between Hispanics and Whites in the rate of alcohol use disorders. In con trast, the Epidemiologic Catchment Area Study, a similar study that reported survey data from the general population as well as an institutional ized population (Helzer et al. 1991), found that Hispanics have higher rates of alcohol use disorders com pared with Whites. Data from the NLAES reveal that Whites are more likely than Blacks to develop alcohol dependence, but no more likely than Hispanics (Grant 1997). In addition, Blacks and Hispanics are more likely than Whites to continue their alcohol dependence once it begins.
Heterogeneity in alcohol abuse and dependence also exists within groups with the same national ori gins. For example, among people of Mexican origin in the United States, Mexican Indians have higher rates of lifetime alcohol abuse or dependence than non-Indian Mexicans (Alderete et al. 2000). However, these differ ences are not significant after the effects of other sociodemographic fac tors are taken into account.
Heterogeneity in alcohol-related problems also varies by place of birth. For example, U.S.-born Mexican American women have higher rates of alcohol dependence than Mexican American women born outside the United States (Caetano et al. 1998).
Research has also compared the prevalence of specific alcohol-related problems, such as drinking and driv ing, for different ethnic groups. A national probability study conducted in 1995 revealed that White and Hispanic men had higher rates of driving after drinking enough "to be in trouble if stopped by the police" in the previous 12 months (22 percent and 21 percent, respectively) compared with Blacks (14 percent) (Caetano and Clark 2000). Among Hispanics, those born in the United States were approximately three times more likely to engage in drinking and driving than those who were born elsewhere. Hispanic men also had higher rates of ever having been arrested for driving under the influence of alcohol (19 percent), compared with White (13 percent) and Black (11 percent) men. Compared with other ethnic groups in Alaska, Alaska Natives had higher rates of car crashes and resulting injuries as well as arrests for driving while intoxicated (Segal 1998).
Research has also examined ethnic differences in alcohol-related violence between spouses or intimate partners. A national probability study con ducted in 1995 revealed that the pres ence of alcohol-related problems, defined as either symptoms of alcohol dependence or drinking-related social consequences, was a strong predictor of intimate partner violence among Black couples, after controlling for the influence of sociodemographic factors, psychosocial variables, and level of alcohol consumption (Cunradi et al. 1999). Alcohol-related problems among both males and females were significant predictors of male-to-female partner violence as well as female-tomale partner violence among Blacks. However, the relationship between alcohol-related problems and intimate partner violence for Whites and Hispanics depended on the context. For example, alcohol-related problems among females were significant predic tors of female-to-male partner violence for Whites but not for Hispanics.
In addition to the legal and social problems discussed thus far, alcohol use is also a factor in rates of death from various causes. Ethnic differ ences in deaths from alcohol-related cirrhosis and from car crashes are described below.

Alcohol-Related Mortality
Alcohol abuse and dependence are associated with several medical prob lems. Cirrhosis mortality, however, usually serves as an indicator of the effects of heavy alcohol consumption in a population because heavy drink ing is the most important risk factor for this disorder (Makimoto 1998).
For 1999, "chronic liver disease and cirrhosis" does not appear among the top 10 leading causes of death for Whites, Blacks, or Asians and Pacific Islanders (Centers for Disease Control and Prevention 2001). However, it was the sixth leading cause of death for both Hispanics and American Indians/ Alaska Natives. Among Hispanics, the largest group of cirrhosis decedents was of Mexican background (Stinson et al. 2001). Compared with Whites, Hispanics have a higher prevalence of hepatitis C, a serious infectious liver disease that greatly increases the risk for liver damage in heavy drinkers (Lieber 2001). In 1997, Blacks had lower mortality rates for cirrhosis than Hispanics but higher rates than Whites (Stinson et al. 2001).
Among males ages 55 to 64 in each ethnic group, however, "chronic liver disease and cirrhosis" is one of the top 10 leading causes of death (Anderson 2001). The rates at which these disor ders occurred in 1999, per 100,000 men in this age range were: 34.7 for Whites, 45.3 for Blacks, 100.6 for Native Americans, 11.5 for Asians and Pacific Islanders, and 61.8 for Hispanics (Anderson 2001). Blacks and Hispanics may have had higher rates of these disorders than Whites in part because both Blacks and Hispanics had higher rates of frequent heavy drinking than Whites, although their rates of drinking were lower than those of Whites (Caetano and Clark 1998a).
The rates of alcohol-related motor vehicle fatalities also vary among eth nic groups. Between 1990 and 1994, Whites and Blacks had similar rates of alcohol involvement in motor vehicle fatalities (44.2 percent and 45.2 percent, respectively) (National Highway Traffic Safety Adminis tration [NHTSA] 1999). Among Hispanics, the proportion of motor vehicle fatalities that were alcohol related was 54.6 percent for Mexican Americans and 36.6 percent for Cuban Americans. Native Americans had the highest rate, at 68.1 percent, and Asians and Pacific Islanders had the lowest rate, at 28.2 percent (NHTSA 1999).
Thus far this paper has focused on how rates of consumption and alcoholrelated problems and mortality vary for different ethnic groups. The next sections address the possible reasons for these variations.

Explaining Ethnic Differences in Alcohol Use
Social and cultural factors as well as biological factors are thought to account for the differences in alcohol consumption and related problems among ethnic groups.

Social and Cultural Factors
Alcohol use patterns can be influ enced by social and cultural factors such as ethnic groups' norms and atti tudes regarding alcohol use and the extent of their acculturation to the larger U.S. society. A group's norms refer to how one should behave in relation to alcohol-for example, beliefs about how much drinking is appropriate for a parent in the pres ence of small children, for a man at a bar with friends, or for someone at a party at another person's home. A group's attitudes refer to general beliefs about drinking, such as whether drinkers have more friends, whether a party is not really a party unless alco holic beverages are served, and whether "getting drunk" occasionally is acceptable .
Alcohol norms and attitudes have been found to be strong predictors of drinking . People with more liberal alcohol norms and attitudes are more likely to be current drinkers than are those with more conservative norms and attitudes, based on 9 survey items reflecting whether respondents endorsed "any drinking" in various social settings and 11 items reflecting attitudes toward drinking and drunk enness. Similarly, people who have more liberal norms and attitudes are generally more likely to be frequent heavy drinkers than are those with more conservative beliefs. In national probability samples, both Blacks and Hispanics have reported more conser vative alcohol norms and attitudes than Whites , which are reflected in the greater abstention rates (shown in table 1) among Blacks and Hispanics than among Whites. Hispanics also seem to have more extreme attitudes toward alcohol than Whites and Blacks (Caetano and Medina Mora 1990). In other words, their views are usually both positive and negative about the consequences, both good and bad, associated with drinking.
In addition to an ethnic group's alcohol norms and attitudes, the degree to which a group is acculturated to the larger U.S. society also influ ences alcohol use among its members. Among Hispanic men, the drinking patterns of those who are more accul turated more closely resemble drink ing patterns among the general U.S. population than those of less accul turated Hispanic men. Acculturation was based on 12 survey items measur ing areas such as the daily use of and ability to speak, read, and write English and Spanish; a preference for media in English and Spanish; the ethnicity of the people with whom one interacts; and values thought to be characteristic of the Hispanic way of life (Caetano 1987). Among Hispanic women, acculturation is posi tively associated with drinking at all and with frequent "high maximum" drinking (drinking once a week, or more often, and having five or more drinks at a sitting at least once a year).
This association between accultur ation and drinking patterns has also been found among other ethnic minority groups. Japanese Americans report drinking patterns that are more similar to those of Whites than to those of Japanese living in Japan (Higuchi et al. 1994). The proportion of Japanese men living in Japan who have problems associated with heavy drinking is higher among middle-aged drinkers (30-59 years old) and lower in both the youngest (18-29 years old) and oldest (60 years old and older) age groups. Among Japanese American men, the highest propor tion of drinkers with heavy drinking problems is found among the youngest age group, as is also the case among White American men. This difference between Japanese men in Japan and Japanese American men likely reflects the influence of acculturation.
Acculturation to U.S. drinking patterns, however, may not be the same across different ethnic groups or even for all subcategories of nationali ties within the same ethnic group (e.g., Japanese, Vietnamese, and Cam bodians among Asian Americans). Differences in alcohol drinking patterns among U.S. Whites of various nationality backgrounds have been found to remain stable despite many generations of acculturation (Dawson 1998). Thus, Americans of Irish her itage report a higher frequency of heavy drinking than do White Amer icans in general, and those of English/Scottish, Austrian, Italian, and Greek backgrounds all report lower frequencies of heavy drinking than do White Americans in general.
One factor that contributes to how the association between accultur ation and drinking patterns develops for a particular group or subgroup is the drinking patterns of that group's country of origin. Hispanics from different Latin American countries, for example, bring a variety of drink ing patterns when they migrate to the United States (Caetano 1987). Another factor contributing to the associ ation is the particular place where a person settles. Different regions of the United States have their own drinking norms and customs, and people accul turate to different cultural environ ments (Caetano 1987). Thus, many factors influence the role that accultur ation plays in the development of drinking patterns among ethnic minority groups (Caetano 1987).

Biological Factors
Lower rates of alcohol use and alco holism among Asians and Pacific Islanders appear to be related to a genetic variation prevalent in these populations (Makimoto 1998). Specifically, Asians are more likely than Whites to have a specific variant of a gene (i.e., an allele) called the alde hyde dehydrogenase-2 (ALDH2) Lys 487. This allele causes the body to break down alcohol in such a way that a person with the allele experiences symptoms such as facial flushing, nausea, headache, dizziness, and rapid heartbeat-collectively known as the flushing response-after consuming alcohol. Because of the presence of this allele, Asian populations tend to consume less alcohol and have lower levels of alcoholism than other ethnic groups (Makimoto 1998). This allele therefore may provide Asians some protection against heavy drinking and alcoholism (Yin et al. 1988;Makimoto 1998). The presence of the ALDH2 allele varies among Asian groups in the United States. In a study of college students, researchers found that 48 percent of students of Chinese ancestry had this allele, compared with 35 percent of students of Korean background (Luczak et al. 2001). The Chinese students also had a lower rate of binge drinking (7 percent) compared with the Korean students (30 percent).

Other Proposed Factors
Other hypotheses have been advanced as explanations for the differences in drinking patterns among ethnic groups, but have not been supported by research findings. The first suggests that machismo, an exaggerated view of masculinity, plays an important role in the heavy drinking patterns of Mexican Americans. Close examination of machismo among White, Black, and Mexican American men, however, has shown that machismo is related to alcohol use among men irrespective of ethnic group and that it is not a valid explanation for the high levels of drinking among Mexican Americans (Caetano et al. 1998;Neff et al. 1991).
A second unsubstantiated hypoth esis has attempted to explain the heavy drinking patterns of Native Americans by suggesting that they are biologically predisposed to heavy drinking and unable to control their drinking. The problems with this hypothesis are, first, that Native Amer icans do not appear to have a greater physiological or psychological reac tion to alcohol than do members of other ethnic groups, and, second, that Native American groups in the United States vary greatly in their alcohol use (Caetano et al. 1998).
Single-variable explanations, such as these for Mexican Americans and American Indians, are often inade quate to explain the ethnic differ ences that exist in drinking patterns (Caetano et al. 1998).

Alcoholism Treatment
In contrast with the amount of infor mation available on the drinking patterns and alcohol-related problems of ethnic minority populations, research on alcoholism treatment with these groups is very limited (Caetano 1993). This is true in spite of the fact that both Hispanics (Arciniega et al. 1996;Caetano 1993) and Blacks (Kaskutas et al. 1999) are over-represented in treat ment compared with their proportions in the general population. Information on alcoholism treatment is especially lacking for Asians/Pacific Islanders.
Nonetheless, the alcoholism treat ment literature does reveal some eth nic differences. Kaskutas and col leagues (1999) found that a higher proportion of Blacks in treatment report having had some previous treatment compared with Whites. In addition, Blacks are more likely to have gone to inpatient programs and Whites to driving-under-the-influence programs. Blacks are almost twice as likely as Whites to have gone to Alcoholics Anonymous (AA) meetings as a part of their treatment. Blacks are also more likely than Whites to report having a spiritual awakening through being in AA and to have served at an AA meeting (e.g., by helping newcomers, setting up chairs, making coffee, cleaning up after a meeting). Whites are more likely than Blacks to report having a sponsor and reading AA literature. Arroyo and colleagues (1998) found that Hispanics in treatment attend significantly more formal alco holism therapy sessions and fewer AA meetings than Whites. Nonetheless, the different treatment options result in similar post-treatment drinking outcomes. The authors speculate that Hispanics may make greater use of their existing social support system and thus may not need AA as a support system, or that their treatment preferences may reflect a belief that AA is not as effective as formal treat ment programs. The extent to which these findings may be generalized to other Hispanic populations may be limited by the fact that the Hispanics studied by Arroyo and colleagues (1998) were generally highly acculturated.
Limited research is available on the results of behavioral treatments and pharmacotherapy with Native Amer icans and Alaska Natives (Abbott 1998). Given the diversity of Native American and Alaska Native tribes, AA may be more appropriate for use by some tribes than others (Abbott 1998). The AA treatment that is used by these populations is often modi fied to meet their particular needs. In addition, given the many socioeco nomic problems faced by many Native American and Alaska Native communities, such as high unem ployment and low family incomes, Abbott suggests that focusing only on the alcohol-abusing segment of the population may be shortsighted. Efforts to address other community problems should at least parallel the development of appropriate alco holism interventions. (See the recent research monograph published by the National Institute on Alcohol Abuse and Alcoholism [Mail et al. 2002] for more information on alcoholism treatment in this population.)

Conclusion
The alcohol literature demonstrates that much variation exists in alcohol consumption, alcohol-related prob lems, and other issues among and within specific ethnic groups. An awareness of these differences can assist in identifying the subpopulations most at risk for developing alcoholrelated problems.
Additional research is needed to address the gaps that currently exist in the literature. Many of the large national probability studies examining alcohol use focus primarily on Whites, Blacks, and Hispanics and do not include Asians/Pacific Islanders or Native Americans/Alaska Natives. Also, limited research exists on the alcohol consumption patterns of the newer immigrant populations in the United States. Alcohol use patterns for the longer-established Asian American populations of Chinese and Japanese may not reflect the patterns of the more recently settled popula tions of Southeast Asians such as Cambodians, Laotians, and Vietnam ese (D'Avanzo 1997).
Further research is also needed on alcoholism treatment outcomes for ethnic minorities, including both general treatment interventions and those developed for particular minority groups. Information about ethnic group differences can be used to develop alcoholism treatment programs that are culturally specific or culturally sensitive (Caetano and Galvan 2001). Culturally specific programs are those developed for a particular ethnic group. Culturally sensitive programs incorporate elements from a given culture, such as language, cultural symbols, and so on, in programs that have been developed for the majority population. Presumably, interventions that are culturally specific are also culturally sensitive; however, inter ventions that are culturally sensitive need not be culturally specific. Both culturally specific and culturally sensitive programs are intended to be more acceptable to ethnic minority communities and hence more utilized by them.
To make alcoholism treatment more culturally sensitive for Hispanics, for example, it may be important to consider that the family plays a very important role in Hispanic culture, with family relationships bound by a strong sense of loyalty and reciprocity (Gaines et al. 1997;Lawrence et al. 1992). For this reason, alcoholism treatment programs for Hispanics may be improved by increasing family involvement.
Further research is needed to show whether culturally specific and culturally sensitive programs in fact yield better treatment outcomes than generic treat ment programs, and whether treat ment outcomes for these different types of programs vary by ethnic group. It is possible that long-established ethnic groups (such as Blacks) may be more likely to benefit from generic treatment programs than ethnic groups of more recent arrivals (such as the Hmong). It is also possible that the advantage of culturally specific or culturally sen sitive programs is not so much based on their effectiveness but on the fact that they are better than generic programs at attracting and retaining ethnic minority clients.
Interventions with ethnic groups can also be developed to target the wider community, for example, by addressing the environmental factors that affect alcohol-related problems, such as the number of alcohol vending outlets in a particular neighborhood (Alaniz 1998). This type of effort may be appropriate in many commu nities with disproportionately high concentrations of alcohol vending outlets and alcohol advertising (Alaniz 1998).
Measures such as these-developed as a result of the work of alcohol researchers, treatment providers, and policymakers-can help decrease heavy drinking and alcohol-related problems among ethnic groups. ■